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25-072 mass save CCIFINICTON PERMIT AUTHORIZATION FORM I, {'Zg,be43, -c, _ 5h e, cv- , owner of the property located at: (Owner's Name, printed) 3S tZ iv2,4 b itivt (� , t2occ c( N0 v aw► p -t-rA4 t MAt/k 0 to t, 0 (Property Street Address) (City/Tbwn) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and /or weatherization work on my property. lit Owner's Signature 011 Lo Jt Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Participating Contractor Date Rev. 12132011 4.-- NlaNsachti■erts - Department of Public StIcrt I Board ot Builrlin2 Rc2tilation. and standard. ,‘,.- .Cc.)nstruction Supervisor Specie", LicP--e „i_ 09S72 Restricted to: WS IC JOSEPH GORGE 64 HAYWOOD STREET r . N GREENFIEW, MAO 301 .144 - --------- Expiration: 2/11/2013 ( , nmn, I Tr 99372 _ — License or registration valid for individul use only --2l3fte-6----ere-afiat-Ille-(IN ''' Office o. onsumer r. Airs , siness egu a io before the expiration date. If found return to: ..,—.. Office of Consumer Affairs and Business Regulation - : 10 Park Plaza - '''', V (7- Registration ° l I l E IMPROVEMENT l I i PR IS Suite 5170 _ ,--- r - VE1M56E6N8T6 Type CONTRACTOR Private Corporatio Boston, MA 02116 ...-,, F.--7-7 Expiration: 7/25)2013 ‘='--= JP & SON INC JOSEPH GEORGE I Not valid itho signet re 1 GREENFIELD, MA 01301 Undersecretary ,., Office of Investigations „ A� 600 Washington Street . ;7411=r1"-- I Boston, M4 02111 � .- www.mass-gov /dit Workers' Compensatfon Insurance AfdaVit: Builders /Cod►tracturs/.ElectrielansIP bers A , , ticamt Information "'" > j �r l ;� Plejase Print Legibly Name Qau ess/orgarizatian/Individual): _P. C t&'4 & E £ S } t ; ' ` . Ad` ress.- - W--1, ` it W '� S City/State/Zip: �_ - - Lkt_� -kC� \ \ C 3O% - Phone #: ��� -I `- i 13 Are you an employer? Check the box: - Type of project required): 1. tll I am a employer With ''•l 4. 0 I am a general contractor and I g New consliltction employees (f_Qll_and/or paxt tame)." have hared the sub - cons actum 2. ❑ I am a sole proprietor orpar ner- listed on the attached sheet T 7. ❑ Remndeiag ship and have no employers These sub;contractors have S. ❑ Dentotitio ' working for me in atly capacity workers' comp. insurance. 9. ❑ Building addition [NTo viorkers' con instaaace - 5. El We are a ccxpora anti its - i0.❑ Electrical - epans or additions req ] °facers ]lave exerc their 3. ❑ i a ll DWne1 doing all w+Orl[ iiglitofegenpt ai1pez'MGL i = .❑ Plumbz ig repairs or ac'lditioos myself [No workers' comp. : 'c. 13.2i 1(4)4nd - 9,;T no I2_0 Roof repass instaance requital] fi employees •0 workers' come- tsuranceiequnred.J 13-Dg Ot}Ier n)'11� + f "Any applicant checha 1 ,X #1 must also fill out the section below th ovhng their waxkeis' compensetioa policy in tian t Homeowners who submit thin affidavit i ndicating:they sin doing s11 titid bucautside w nctors submit a new affda -it indiceling such. ;Contraction that check Ibis b o a - m u s t attached nn additional s h e e t s h o w i n g the name ofthe aria- contraetols and their workers' comp_ T-olicy „ay. ti oa I owl tut employer that is providing work er.= conyiensatioe ansnrnnee for my employees Below is the policy and job site tnf iv>L Insm'ance Company Nalate: . V t1 ' Policy if or Self -ins. L.ic. f: z ' �- i 5 Cpl /3 Expiration Date: - : 1 -41 ■ 3 Job Site Address; 3 S Riv el' boo IS DNA City/State/Zip:. NOrtiv mptot' MI\ oto ° Attach a copy of the workers' compensation polfey cleciaratioa page (showing the policy number and expiration date). Pails to secure coverage as required under Section 25.A of IVIGL c: 152 can lead to the i oposition o :: emir final penalties of a ne up to $ 1,500.00 andfor one imprisonment as= wellas'civapenaliies in the form of a STOP WORT ORDER and a fine of up ix) $250.00 a day against the violator. Be advise&that=a copy-of this statementmay be forwarded to t tc Office of Invcsngations of the D1.A for insurance coverage verification. - - I do hereby certify rustler they a • , , - , enables o. f perjury't ai the information provided above is true arid correct Simatuxe: jai '' • _ - Date: 611 - 6 - 101a Phone . { 4 E) 1-1 .� 6 : ` :. _..._ Official use only. Do not write in this ai ea, to be compieledbyy city ort v officiaL • City or Town: - - -- - - -- Fermitalcense r Issuing Authority (circle uneye - . :... I. Board ofIlealt1z 2_ Building Department 3. City/Town Clerk 4 Electrical Inspector 5_ filurating Inspector 6. Other • Contact Person: Phone #: a �N City of Northampton i r, ' , '_ a Massachusetts � *`' r, ': 1 * ,„ ' " DEPARTMENT OF BUILDING INSPECTIONS . 1 fi 212 Main Street • Municipal Building J4. ` Northampton, MA 01060 Is % Property Address: 5 , + ver\ - RocnA Not \ , MI\ OI °I,o Contractor Name: a p, c, or3e ov,A So he, / Sos &' Georit Address: b9 \-kA kree\ City, State: (T r e ° 4, ,e 1c\ , N1 A Phone: 11 '36 Property Owner Name: R el t CCrn S rE'.Y Address: 35 ( RoG4 , ti rn . City, State: NortwcrnPion , AA 1 0I b0 I, J6z0\ L (� oC:\E' (contractor) attest and affirm that the building I intend to insulate does not have any open air (knob and tube) wiring in the spaces to be insulated and that I have provided the property owner with a copy of this affidavit. Contractor signature Date _ C\ ^ L, 3.( \7. SECTION 8 - CONSTRUCTION SERVICES 8.1 Licensed Construction Supervisor: Not Applicable ❑ Name of License Holder : V 0 -W b c-e or t SS c1 0 License Number L9 H G y w o D a \ St , Greet e 1 u 1 ,� , MA 03 01 . I I - .),D i 3 Addr s �//� /A Expiration Date Signatu a Telephone J 9. Registered Home Improvement Contractor: Not Applicable ❑ T, p. (Tent } so r, Z nt . 1.1, 68b Company Name Registration Number C Ntiyw000k St (Trews clA j MA ©1301 7- ,)c-A313 Addres• Expiration Date Telephoned 1 :) _7 71-31)04 — SECTION 10- WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152, § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes tEl No ❑ 11. - Home Owner Exemption The current exemption for "homeowners" was extended to include Owner occupied Dwellings of one (1) or two(2) families and to allow such homeowner to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. CMR 780, Sixth Edition Section 108.3.5.1. Definition of Homeowner: Person (s) who own a parcel of land on which he /she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/ or farm structures. A person who constructs more than one home in a two - year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official, that he /she shall be responsible for all such work performed under the building permit. As acting Construction Supervisor your presence on the job site will be required from time to time, during and upon completion of the work for which this permit is issued. Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153 (Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts General Laws Annotated, you may be liable for person(s) you hire to perform work for you under this permit. The undersigned "homeowner" certifies and assumes responsibility for compliance with the State Building Code, City of Northampton Ordinances, State and Local Zoning Laws and State of Massachusetts General Laws Annotated. Homeowner Signature SECTION 5- DESCRIPTION OF PROPOSED WORK (check all applicable) New House ❑ Addition ❑ Replacement Windows Alteration(s) n Roofing ❑ Or Doors EJ Accessory Bldg. ❑ Demolition ❑ New Signs [O] Decks [17J Siding [CI] Other [Q] Z nSt,k)tto. Brief Descri tion of Propoo,sed p Work: if Sfol 00'1 ;1 u rI v,,s( leick AtItc 7 Of CP?gU(oSe to 0,-A; 0 ] on Alteration of existing bedroom Yes No Adding new bedroom Yes No Attached Narrative Renovating unfinished basement Yes No Plans Attached Roll - Sheet 6a. If New house and or addition to existing housing, complete the following: a. Use of building : One Family Two Family Other b. Number of rooms in each family unit: Number of Bathrooms c. Is there a garage attached? d. Proposed Square footage of new construction. Dimensions e. Number of stories? f. Method of heating? Fireplaces or Woodstoves Number of each g. Energy Conservation Compliance. Masscheck Energy Compliance form attached? h. Type of construction i. Is construction within 100 ft. of wetlands? Yes No. Is construction within 100 yr. floodplain Yes No j. Depth of basement or cellar floor below finished grade k. Will building conform to the Building and Zoning regulations? Yes No . I. Septic Tank City Sewer Private well City water Supply SECTION 7a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT k `ek Co a r , as Owner of the subject property hereby authorize `So3P, P, Geo r 4- to act on my behalf, in all matters relative fo work authorized by this building permit application. See (A1.14 ° I - a91/ Signature of Owner Date 0 (\ (, , as Owner /Authorized Agent hereby d clare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. J se.h Geo Print Name \A\ Signature of Owned' . e t Date AEC V;_: C of Northampton Status of Permit: Department use only -- 1 B ilding Department Curb Cut/Driveway Permit CF P _ 7 me 212 Main Street Sewer /Septic Availability Room 100 Water/Well Availability No hampton, MA 01060 Two Sets of Structural Plans n o rHA7i p1 13 87 -1240 Fax 413- 587 -1272 Plot/Site Plans ` `" Other Specify APPLICATION TO CONSTRUCT, ALTER, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING SECTION 1 - SITE INFORMATION This section to be completed by office 1.1 Property Address: 35 R,ver & R ook NO 1` &$vpto n MIN Map Lot Unit O r Zone Overlay District 0 Elm St. District CB District SECTION 2 - PROPERTY OWNERSHIP /AUTHORIZED AGENT 2.1 Owner of Record: Rpbecc■ Seer 35 Pierl R000 Norfi1,UolYsf / to 0106D Name (Print) Current , n Address: S t?t 0014 c4 I Telephone Signature 2.2 Authorized Agent: 31)SePh GQotd til Nu wyA s}, (rreenf',elA MA Olili 1 Name (Print '� Current Mai ing Address: , , i 1 c' �• r _ ( I . C A' bI l- 779) o 4 Signature Telephone SECTION 3 TIMATED CONSTRUCTION ONSTRUCTION COSTS Item Estimated Cost (Dollars) to be Official Use Only completed by permit applicant 1. Building (a) Building Permit Fee 2. Electrical (b) Estimated Total Cost of Construction from (6) 3. Plumbing Building Permit Fee 4. Mechanical (HVAC) 5. Fire Protection 6. Total = (1 + 2 + 3 + 4 + 5) At a) 071 . El Check Number �� 1 55 This Section For Official Use Only Building Permit Number: Date Issued: Signature: Building Commissioner /Inspector of Buildings Date File # BP- 2013 -0265 APPLICANT /CONTACT PERSON JOSEPH GEORGE ADDRESS/PHONE 64 HAYWOOD ST GREENFIELD (413) 774 -3604 PROPERTY LOCATION 35 RIVERBANK RD MAP 25 PARCEL 072 001 ZONE THIS SECTION FOR OFFICIAL USE ONLY: PERMIT APPLICATION CHECKLIST ENCLOSED REQUIRED DATE ZONING FORM FILLED OUT Fee Paid Building Permit Filled out i�h�� Fee Paid `�`CJO 0 7`E' Typeof Construction: AIR SEAL ATTICBASEMENT & INSULATE ATTIC New Construction Non Structural interior renovations Addition to Existing Accessory Structure Building Plans Included: Owner/ Statement or License 99372 3 sets of Plans / Plot Plan THE FOLLOWING ACTION HAS BEEN TAKEN ON THIS APPLICATION BASED ON INF9kMATION PRESENTED: Approved Additional permits required (see below) PLANNING BOARD PERMIT REQUIRED UNDER:§ Intermediate Project: Site Plan AND /OR Special Permit With Site Plan Major Project: Site Plan AND /OR Special Permit With Site Plan ZONING BOARD PERMIT REQUIRED UNDER: § Finding Special Permit Variance* Received & Recorded at Registry of Deeds Proof Enclosed Other Permits Required: Curb Cut from DPW Water Availability Sewer Availability Septic Approval Board of Health Well Water Potability Board of Health Permit from Conservation Commission Permit from CB Architecture Committee Permit from Elm Street Commission Permit DPW Storm Water Management Demolition Delay Signature of Building Official Date Note: Issuance of a Zoning permit does not relieve a applicant's burden to comply with all zoning requirements and obtain all required permits from Board of Health, Conservation Commission, Department of public works and other applicable permit granting authorities. * Variances are granted only to those applicants who meet the strict standards of MGL 40A. Contact Office of Planning & Development for more information. 35 RIVERBANK RD BP- 2013 -0265 GIS #: COMMONWEALTH OF MASSACHUSETTS Map:Block: 25 - 072 CITY OF NORTHAMPTON Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A) Category: INSULATION BUILDING PERMIT Permit # BP- 2013 -0265 Project # JS- 2013- 000433 Est. Cost: $2071.00 Fee: $55.00 PERMISSION IS HEREBY GRANTED TO: Const. Class: Contractor: License: Use Group: JOSEPH GEORGE 99372 Lot Size(sq. ft.): 12850.20 Owner: SCOTT LINDA D & REBECCA L SHEV Zoning: Applicant: JOSEPH GEORGE AT: 35 RIVERBANK RD Applicant Address: Phone: Insurance: 64 HAYWOOD ST (413) 774 -3604 WC GREENFIELDMA01301 ISSUED ON :9/13/2012 0 :00 :00 TO PERFORM THE FOLLOWING WORK :AIR SEAL ATTIC /BASEMENT & INSULATE ATTIC IN PROGRESS INSPECTION REQUIRED POST THIS CARD SO IT IS VISIBLE FROM THE STREET Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector Underground: Service: Meter: Footings: Rough: Rough: House # Foundation: Driveway Final: Final: Final: Rough Frame: Gas: Fire Department Fireplace /Chimney: Rough: Oil: Insulation: Final: Smoke: Final: THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF ANY OF ITS RULES AND REGULATIONS. Certificate of Occupancy Signature: FeeType: Date Paid: Amount: Building 9/13/2012 0:00:00 $55.00 212 Main Street, Phone (413) 587 -1240, Fax: (413) 587 -1272 Louis Hasbrouck — Building Commissioner